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Jan. 31, 2011 -- Immediate imaging with X-rays, CT scans, or MRIs for patients with acute low back pain is not recommended for all patients, according to new guidelines by the American College of Physicians.

The guidelines, which appear in the Feb. 1 issue of the Annals of Internal Medicine, suggest that such imaging tests are appropriate for people with low back pain that may be due to cancer, infection, nerve damage, or pain that worsens despite initial treatment.

Signs of these more serious conditions include weight loss, fever, loss of muscle strength, and/or sensation in the legs and abnormal reflexes in addition to the low back pain.

“Unnecessary imaging exposes patients to preventable harms, may lead to additional unnecessary interventions, and results in unnecessary cost,” conclude researchers led by Roger Chou, MD, of Oregon Health and Science University in Portland.

Chou and colleagues reviewed the literature on the use of routine imaging tests in people with low back pain. By and large, patients with acute low back pain without findings suggesting a specific underlying condition had the same outcome with or without these tests. Some tests, such as X-rays, require radiation and pose a small risk from radiation exposure.

Second Opinion

Daniel M. Walz, MD, chief of the division of musculoskeletal imaging at North Shore University Hospital in Manhasset, N.Y., reads 30-plus spinal MRIs a day. He tells WebMD that the new guidelines got it right.

“Every patient feels their workup isn’t complete without an MRI,” he says. “These imaging places are so present in the community that patients truly feel they should get it, but it doesn’t change anything.”

There are some cases where MRIs or other imaging exams are warranted, he says. “If someone has a history of cancer, and there is a reason to suspect that cancer has spread to the spine, or there is nerve damage, I would suggest an MRI to help determine whether or not surgery is needed.”

At a certain age, almost everyone has findings on MRI, Walz says. “Sometimes we see too much and the imaging doesn’t correlate with the back pain, so this leads us down a road where we are pursuing things that we shouldn’t be pursuing.”

See a Back Pain Specialist for Diagnosis

For example, bulging back discs on an MRI can be seen in many patients without any back pain. A previous study has shown that 90% of people 60 years or older had a degenerated or bulging disc. “A patient hears that they have bulging discs, and says, ‘You have to fix it,’” he says.

“Before you insist on an MRI, see someone who specializes in diagnosing and treating back pain,” he says.

Andrew Haig, MD, a professor of physical medicine and rehabilitation at the University of Michigan in Ann Arbor, says this simple step -- seeing a back pain specialist such as a physiatrist -- can help reduce unnecessary imaging tests and subsequent spinal surgeries by as much as one-third.

Persistent Back Pain

The new guidelines suggest further testing if the low back pain worsens or persists despite a trial of therapy.

Richard J. Herzog, MD, an attending radiologist at the Hospital for Special Surgery in New York City, says, “If pain persists, you would then do appropriate imaging studies to decide the appropriate therapies.”

“Yes, imaging is overutilized, but the more patients are educated, the more these tests will be ordered appropriately,” he says.